Provider Demographics
NPI:1942606645
Name:MOUTHPEACE DENTAL LLC
Entity Type:Organization
Organization Name:MOUTHPEACE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SYRETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-371-1423
Mailing Address - Street 1:1050 MARIETTA ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5522
Mailing Address - Country:US
Mailing Address - Phone:312-371-1423
Mailing Address - Fax:
Practice Address - Street 1:1050 MARIETTA ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5522
Practice Address - Country:US
Practice Address - Phone:312-371-1423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUTHPEACE DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013505122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty